How to Design Physician Engagement Programs that are Meaningful to Physicians

Physicians - no matter where they are in the world, are human beings that have answered a very special calling. To help others.

They have families, vices, leaky toilets, pay bills, go to their kid's dance recitals and sports contests, dogs to walk, aging parents, just like the rest of us. And when it comes to their working lives, they seek balance, need to decompress, and they need help to work smarter, not harder. As a result, many have either changed their work setting to a hospital-owned or larger medical group practice. They have integrated with others into clinical and economically integrated networks, to be able to do more with less in terms of practice management and administration costs and overheads, camaraderie, shared risk management tools (captives and professional liability pools) and are on this never ending journey to focus more on direct patient care than paperwork.

In clinical integration, however, they react poorly (if not with all out abhorrence) to "cookbook medicine" or irrelevant clinical pathways that attempt to control their clinical autonomy. No one argues that reducing clinical variation can have a significant positive impact on resource utilization, resulting in lower costs in areas with high-order volumes such as pharmacy, laboratory, diagnostic imaging, and supply. But they want the rule book to be their own, even if their rule book says the same things as the Milliman Care Guidelines (MCG) or Interqual. It's the fact that nobody asked them first or adapted what's in the book to their local reality. For example, if you don't have a full-time MRI or other piece of technology at your disposal, what good is a clinical pathway or protocol that calls for this as if everyone has one.

I've worked with physicians in rural Nigeria who built their own small neighborhood hospital. I've worked with a physician in Tunisia who had no advanced technology whatsoever in Tunis and Carthage until he built the hospital and brought this technology we take for granted at Centers of Excellence throughout the urban areas of the USA. I've worked with physicians in Appalachia and in parts of Utah where people must drive 3+ hours to access a specialist in a common specialty.

Using my training as a nurse, my understanding of the entire healthcare delivery and reimbursement schema, my understanding of social determinants of health, medical tourism, and physician integration and alignment, one of the projects I enjoy most of all is helping the doctors to rewrite their own rule book for use within an integrated and aligned network of clinically and economically integrated physicians. One thing I've noticed anecdotally is that the integration alone doesn't work. Clinical integration alone works better that mere integration without alignment of interests.

Want the "Mac Daddy" of them all? The magic happens when they have all the spokes in the wheel: the clinical integration and economic integration, their own rule book, and a way to push aside the business of healthcare and let them be doctors who treat patients and to own the wheel itself or at least and equal share of the wheel.

In my experience, physician engagement that is meaningful and economically integrated usually results in agreement on how professional resources will be used, and a rule book that fits their unique circumstances, and enables them to deliver care they are proud to deliver. It also reduces the variety of resources required for specific cases.

I've proven this time and time again in a number of consulting projects with hospitals and ASCs where I trimmed out 30-35% of the cost per case in the operating theater, cut room turnover time significantly enough to fit in 1-2 additional cases per theater.

My approach in these projects has resulted in more margin per case, less shelf space and cash for storage of those resources, supplies, implants, prosthetics sitting on shelves waiting to be consumed, reduced red bag waste, smaller instrument trays with fewer items to count and track, reduced anesthesia time, faster PACU time, and fewer surgical complications. This model enables the gainsharing with the facility and tracks back to the shared risk and economic integration. When the claims can be submitted through a commonly held MSO, contracted through a shared highly-skilled contract analyst and negotiator that they could not afford individually, additional cost containment occurs. But without economic integration and shared financial benefit from playing on this winning team, however, the physicians are not "as motivated" or aligned to engage because the benefit is not complete. That's why, in a physician setting with a not-for-profit hospital (the majority of U.S. hospitals) PHOs and ACOs that are clinically integrated but not economically integrated and aligned have so much trouble with physician engagement: They do all the right things and find all the eggs at the egg hunt, including the golden egg, but they don't get to take home their winnings.

The analysis and understanding of utilization of these resources should be incorporated into the rapid design phase of the clinical redesign effort. This is a part of branding and #servicedesign as much as it is a benefit to patients and clinical efficacy.

In my projects, I've always found that clinical variation is not only caused by what products/services are being used, but also how much of each product/service is being used in each clinical situation as prescribed by the physician. But to do this, I had to draw upon my surgical nurse experience and in the surgical projects, get the doctors to agree to agree. This was one of the elements of their own self-authored rule book.

In the internal medicine and sub specialty projects I've completed, agreeing to agree was critical to writing self-authored clinical pathways. Reducing clinical variation always resulted in reduced patient days/census in ICU, general acute and rehab beds, as well as lower or more appropriate and less redundant tests and procedure ordering volumes. That means trouble for a hospital with financial projections and results in misalignment unless there's a way to counteract that effect. Margin widening by cutting costs elsewhere neutralizes this to some extent. There's usually lots of room for improvement in cutting margins and increasing throughput and efficiency. Several years worth, in fact.

In addition, decisions made for physicians by physicians as to “who” will deliver various aspects of care was one of the main outputs of the work I did on these projects to integrate into pathways and protocols. And this is by no means anecdotal. I've been doing this since the first project I was hired for in 1993 in Houston and I've realized 100% success in cutting costs and improving clinical efficiency while improving clinical outcomes across 70+ projects in the past 25 years. The cost for me to do these projects is under $50,000 and done in 4-6 months, sometimes less. What the integrated health system recuperates in margins more than pays for the project in 5 surgery cases. And that's really how it must be analyzed, as a return on investment that turns out to pay dividends again and again and again as long as the engagement and clinical and economic integration and alignment are in check.

Value analysts and operational improvement teams tend to agree that a focus on reducing clinical variation always changes the department’s approach to some degree. As long as there are reporting mechanisms that are easy to use the data collected and interpreted helps ensure the clinically integrated network is operating appropriately and on course for financial and patient satisfaction gains and clinical improvement.

After physician integration alignment and engagement comes staffing improvement; not the reverse

A second level to this is the ancillary organization. First you tackle the physician engagement, and then, once their playbook is published, you refine by improving the pathways for ancillary services. In my projects, many hospitals tried to do this in reverse because they employ 100% of the ancillary staffers and didn't always employ 100% of the physicians. So they went after what they could "control" first. That hasn't seemed to work as well as when you engage the physicians first. And if you really believe you can control physicians, you are kidding yourself.

With effective productivity monitoring tools and practices in place for flexing to volume, staffing levels throughout the organization will be positively impacted. That requires cross training in most cases, though and if the training budget is too skimpy, the cross training doesn't occur and the planned approach breaks down. Any time you can reduce dependence on outside pool nursing and use voluntary overtime for regular staff, you increase charge capture accuracy and charge selection accuracy. One consultant I know well did a study of a few hospitals with $1m in charges to determine charge capture errors and found that with the standard line item entries in the CDM limited to 54 characters or so, nurses from an outside pool tended to click the first listing of an item instead of the correct listing of an item, leading to inaccurate billing, embarrassment with auditors, misalignment with clinical documentation, and RAC audit and payer adjustments. They also found that approximately $300 per shift/per day/per temp nurse in missed charge capture was occurring. That's a lot of avoidable error and cost for not having adequate or flex staffing and adequate cross training and labor resources.

In a study published in the American Journal of Nursing , the pool nurse utilization resulted in an average 1-day longer length of stay and higher hospital-acquired infection rates. The higher infection rate was probably nosocomial rather than contamination by the pool nurses. I can't remember because the article was published more than 10 years ago. But if those extra days are then "trimmed" and not paid by third party payers because they are determined to be medically "unnecessary", everyone works and feeds and cares for the patient for no gain, and the patient ends up losing because of the increased risk for hospital-acquired infection. This damages quality and service satisfaction.

Reductions in overtime and other premium labor dollars have also been achieved through the elimination of throughput issues due to the improvements in clinical redesign. But you won't realize it on paper unless you have sufficient productivity and outcomes reporting in place to capture the impact on changes in order volume and LOS, and be able to translate the changes in workload to decreased labor costs and right-sized staffing levels. So again, if the physicians are not economically integrated and aligned and engaged, coupled with sufficient reporting formats, the savings are not attributed to the engagement and the clinical redesign and they don't get credit for finding the eggs. If the eggs in the egg hunt are not properly accounted for it is as if they were never found to begin with. The result is the same: No gainsharing benefit to be shared with the physicians for doing the right things, the right way. Capturing this cost savings is part of the scorecard for evaluating the cost benefit of #clinicalredesign and #servicedesign and reducing clinical variation through economically integrated, aligned and engaged physicians working as a team.

When physician engagement shifts care delivery from high-volume to high-value, you know you're on the right pathway

Implementing #clinicalredesign and reducing clinical variation can change the outcomes critical to shifting care delivery from high-volume to high-value. Working with clinicians to implement a care delivery process that eliminates unnecessary care and is aligned with best practices often results in improvements to key quality indicators such as readmission and complication rates. But only if they adopt and follow them. That's where the self-authored playbook is the differentiator. You can lease a copy of the Milliman MCGs or Interqual as a base, but they doctors must believe in their heart and soul that you are not trying to control and constrain their clinical autonomy from a medical recipe book they didn't approve or author. I learned that it isn't the words on the paper in the order of appearance in a sentence. It is that they participated in confirming it was correct or were involved in the modifications however slightly. Standardizing specific elements of care delivery results in a more predictable care path and allow providers and staff to set patient expectations, improve patient satisfaction, and ultimately promote safer care. It also facilitates the creation of more standardized, less financially risky bundled case rate creation.

Using care navigators (another one of the spokes in my wheel, above) the overheads of which cannot be absorbed by a single independent physician or small group practice can be affordable in the integrated physician setting. When in lockstep with the self-authored play book, the care navigator picks up the slack and saves physician time by enabling communication with patients and allows patients and family members to know prior to, or early upon admission, when to expect to be discharged so that planning by the family can take place. Patient education related to the plan of care and/or pathway also enables information transfer to the patient and family involved in care progression. This is a critical aspect of meeting the ever increasing expectations of the level of satisfaction of patients and their families and lowering "unnecessary" extensions in length of stay, which then reduces consumption and staffing and risk of nosocomial infection.

Wrap up

All of these actions and elements assimilated together shrink overheads and help mitigate margin erosion. When these eggs are counted and taken home by the physicians, every egg accumulated translates to more dollars in their bank account and reinforces their commitment to remaining engaged and upholding brand differentiation standards and integrity. This aids competition and negotiation for contracts with payers an gives people like me who contract for many integrated physician and physician-hospital groups a lot more substance to use in the negotiation instead of simply asking for higher reimbursement without a reason the payer realizes as "value".

No matter what ends up happening in U.S. healthcare reform going forward, I haven't the slightest doubt in my mind that #clinicalredesign and #servicedesign enabled through physician integration alignment and engagement will remain relevant. Using the tactics and strategies I mentioned above will outlast any temporal trends or fad approaches to cost containment, clinical efficacy and business efficiency of a clinically and economically integrated network.